Quality Improvement Program All Lines of Business 2018

Transcription

1 Quality Improvement Program All Lines of Business 2018 Quality Oversight Committee approval on 2/22/18 Compliance and Quality Committee approval on 3/15/ Q I P r o g r a m D e s c r i p t i o n

2 TABLE OF CONTENTS Mission Program Structure... 5 Goals and Objectives 10 Authority and Accountability Organization Structure.. 17 QI Program Physician Leadership 21 QI Program Resources.. 23 Collaboration Through Work Groups.. 37 Behavioral Health Collaboration.. 37 Committee Structure. 38 Scope of Program. 56 Sales and Marketing. 75 Quality Improvement Process and Health Information Systems. 76 Member Confidentiality Confidentiality.. 80 Disease Reporting Statement 80 QI Delegation Annual QI Program Evaluation 82 Annual QI Work Plan Q I P r o g r a m D e s c r i p t i o n

3 MISSION L.A. Care Health Plan s mission is to provide access to quality health care for Los Angeles County s vulnerable and low income communities and residents and to support the safety net required to achieve this purpose. VISION A healthy community in which all have access to the health care they need. VALUES We are committed to the promotion of accessible, high quality health care that: Is accountable and responsive to the communities we serve and focuses on making a difference; Fosters and honors strong relationships with our health care providers and the safety net; Is driven by continuous improvement and innovation and aims for excellence and integrity; Reflects a commitment to cultural diversity and the knowledge necessary to serve our members with respect and competence; Empowers our members, by providing health care choices and education and by encouraging their input as partners in improving their health; Demonstrates L.A. Care s leadership by active engagement in community, statewide and national collaborations and initiatives aimed at improving the lives of vulnerable low income individuals and families; and Puts people first, recognizing the centrality of our members and the staff who serve them. PURPOSE The Quality Improvement Program is designed to objectively and systematically monitor and evaluate the quality, appropriateness and outcome of care and services delivered to our members. The QI Program provides mechanisms that continuously pursue opportunities for improvement and problem resolution. In addition, the QI program utilizes a population management approach to members and providers and collaborates with local, state and federal public health agencies and programs. as well as with providers and other health plans. STRATEGIC PRIORITIES ( ) Goal 1: A highly-functioning health plan with clear lines of accountability, authority and communication, and with processes and people that drive efficiency and excellence Q I P r o g r a m D e s c r i p t i o n

4 Objectives: Ensure timely success of the core system conversion to improve efficiency and core operational functionality. Build a high performance workforce through the attraction, training and retention of high quality talent, capable of meeting the evolving needs of a large and complex heath plan. Drive product line performance by establishing clear lines of accountability to support high-quality service and financial sustainability across all product lines. Enable product line performance through operational improvements and increased functionality. Effective collaboration with vendors and delegated entities, including Plan Partners, PPGs, and contracted providers of behavioral health services, pharmacy services, and transportation providing oversight, feedback and dialog to address deficiencies and identify opportunities to improve care delivery and outcomes. Increase use of data to drive decision-making across product lines and functional areas by centralizing data governance, management, and analytics and establishing tools that facilitate access to data. Optimize the financially responsible growth potential of Cal MediConnect and L.A. Care Covered. Goal 2: A network that aligns reimbursement with member risk and provider performance in support of high-quality, cost-efficient, and member-centric care. Objectives: Optimize shared risk, dual risk and full risk contracting arrangements by product segment to align reimbursement with the specific needs and risk type of the population segment. Develop and implement a scorecard for Medi-Cal provider groups that reflects performance with respect to the Triple Aim, laying the groundwork for value-based reimbursement. Develop and implement strategies to promote quality performance in the provider network. Goal 3: Tailored models of care for the specific needs of our member populations. Objectives: Develop and implement direct networks for subpopulations within our membership to improve access and quality. Develop tailored population health management programs for the unique needs of our vulnerable, high-risk, and other subpopulations. Reduce health disparities through targeted care management and quality improvement interventions Q I P r o g r a m D e s c r i p t i o n

5 Goal 4: Recognized leader in improving health outcomes for low income and vulnerable populations in Los Angeles County. Objectives: Develop an L.A. Care brand that articulates our value proposition. Actively support safety net providers ability to perform their delegated functions and to leverage the investments made in healthcare information technology to succeed in a managed care environment. Mobilize our community resources to ensure that we are responsive and accountable to the needs of our members and constituents. Foster innovative approaches to improving the quality of care provided by the safety net. Collaborate with external organizations such as the Industry Collaboration Effort (ICE), the Integrated Healthcare Association (IHA), California Maternity Quality Care Collaborative (CMQCC) and the California Quality Collaborative (CQC) to learn and share best practices. PROGRAM STRUCTURE L.A. Care s Quality Improvement Program describes the QI program structure, a formal decision- making arrangement where L.A. Care s goals and objectives are put into an operational framework. Tasks to meet the goals and objectives are identified, grouped and coordinated in the activities described in the accompanying QI work plan. The QI program description defines how the organization uses its resources to achieve its goals and includes how the QI program is organized to meet program objectives, functional areas that support the program and their responsibilities and reporting relationships for the QI Department staff and QI Committees. These are described in detail in the program. In addition to Medi-Cal, the following product lines have been added and will be covered by the QI program description: Medi-Cal Expansion, L.A. Care Covered (On- Exchange), L.A. Care Covered Direct (Off-Exchange), PASC-SEIU Plan, and L.A. Care Cal MediConnect Medicare-Medicaid Plan (MMP). The program also supports the integration of Behavioral Health, Substance Use, and Managed Long-Term Services and Supports (MLTSS). L.A. Care Health Plan Community Access Network (CAN) In 2016, L.A. Care filed an Amendment to its license for direct contracting in the Antelope Valley area of Los Angeles County. The Antelope Valley covers a large part of Los Angeles County and contains many sparsely populated areas. Residents have historically experienced challenges accessing care, including physician services. To respond to those challenges, L.A. Care contracted directly with primary care physicians and specialists in that area who are accessible to Medi-Cal members who elect to join the Community Access Network. Due to the relative success of using the direct contracting approach in Antelope Valley, L.A. Care decided to expand the model throughout Los Q I P r o g r a m D e s c r i p t i o n

6 Angeles County. L.A. Care intends to implement the CAN throughout the County geographically by region using L.A. Care s Regional Community Advisory Committee s ( RCAC ) regions in L.A. County. The addition of these providers increased the total number of available primary care physicians, specialists, and mid-levels in the entire LA County from 144 to 273. These providers, along with previously contracted PPG providers, serve the needs of L.A. Care s members they benefit from having a direct relationship with L.A. Care, and have the opportunity to serve members beyond just those assigned to them by the provider group(s) with which they are contracted. In order to maximize the benefits members and providers receive from this new network, L.A. Care took on more responsibility for directly managing the functions which touch our members and providers directly care management, utilization management, and claims. The Community Access Network launched in February A communication plan informing external partners of this new network was developed in 2016In March 2017, we expanded the L.A. Care CAN to, South Los Angeles and Long Beach and in June of 2017 East Los Angeles and Central Los Angeles. We plan to expand throughout Los Angeles County in SB 75 Full Scope Medi-Cal for All Children Under a new law that was implemented May 1, 2016, children under 19 years of age are eligible for full-scope Medi-Cal benefits regardless of immigration status, as long as they meet all other eligibility requirements (Welfare and Institutions Code section ) The Department of Health Care Services (DHCS) worked collaboratively with County Welfare Directors Association of California (CWDA), county human services agencies, Covered California, advocates, and other interested parties to identify impacted children and provide them with full Medi-Cal coverage benefits. At L.A. Care, as of Nov 1, 2017 a total of 21,628 children under the age of 19 have been determined newly eligible for full scope Medi-Cal under SB75. As of Nov 1, 2017, there are 20,308 children under the age of 19 who are currently active L.A. Care members receiving full-scope Medi-Cal under SB75. L.A. Care Covered (On-Exchange-LACC) Under the health care reform, L.A. Care Health Plan has proudly participated with Covered California to offer affordable health care coverage for residents of Los Angeles County, known as L.A. Care Covered. This product line was launched on October 1, 2013 with a focus on serving diverse and low-income communities in Los Angeles County. The health care reform law also assists individuals/family pay the monthly premiums through the Covered California application process. Individuals/families may be eligible/qualify for the federally subsidized rates and/or receive Advance Payment of Premium Tax Credits (APTC) if their income is at or below 400% of the Federal Poverty Line (FPL). The Open Enrollment period for Covered California opens in the fall each year for coverage the following year. Individuals/families who experience an unexpected life event, such as losing a job, may apply for coverage throughout the year during the Special Enrollment period Q I P r o g r a m D e s c r i p t i o n

7 L.A. Care Covered has the most affordable premiums in Los Angeles County for the Silver, Gold and Platinum metal levels. Our plans offer preventive care at no additional cost. Members have access to an extensive network of doctors, specialists, hospitals, pharmacies, and preventive care services - close to where they live, work, and play. A free Nurse Advice Line is available to all members 24 hours a day, 7 days a week. Health education, exercise classes, and disease management programs are available at no cost through our Family Resource Centers. L.A. Care s contract with Covered California includes a multi-year Quality Improvement Strategy (QIS), which includes the following components: Provider networks based on quality Access to Centers of Excellence Hospital quality and safety Appropriate use of C-sections Reducing health disparities Promoting the development and use of care models in primary care Promoting the development and use of care models: Integrated Healthcare Models Patient-centered information and communication Patient-centered information: cost transparency L.A. Care Covered Direct (Off-Exchange-LACCD) On March 1, 2015, a product line operated entirely by L.A. Care Health plan was launched, known as L.A. Care Covered Direct. L.A. Care Covered Direct offers affordable health coverage to residents of Los Angeles County with a focus on serving diverse and low-income communities. Those who do not qualify for financial assistance or prefer to purchase health coverage directly with L.A. Care Health Plan can choose coverage under L.A. Care Covered Direct. L.A. Care Covered Direct offers the same health benefits and services through our four plans (Platinum, Gold, Bronze, and Minimum Coverage) which include: Preventive care at no additional cost. Access to an extensive network of doctors, specialists, hospitals, pharmacies, and preventive care services - close to where they live, work, and play. A free Nurse Advice Line available to all members, 24 hours a day, 7 days a week. Health education, exercise classes, and disease management programs available at no cost through our Family Resource Centers. Quality Improvement Strategy (QIS), which includes the following components: Provider networks based on quality Access to Centers of Excellence Hospital quality and safety Appropriate use of C-sections Reducing health disparities Q I P r o g r a m D e s c r i p t i o n

8 Promoting the development and use of care models in primary care Promoting the development and use of care models: Integrated Healthcare Models Patient-centered information and communication Patient-centered information: cost transparency PASC-SEIU Plan The PASC-SEIU Homecare Workers Health Care Plan (PASC-SEIU Plan) transitioned from Community Health Plan (CHP) to L.A. Care in February The Personal Assistance Services Council (PASC) and the Service Employees International Union (SEIU) developed the plan for In-Home Supportive Services (IHSS) Workers. PASC is the employer of record and contracts with L.A. Care Health Plan to provide member services, claims processing, COBRA/Cal-COBRA billing, and other health plan services. L.A. Care contracts with the L.A. County Department of Health Services and Citrus Valley Physicians Group, which comprise the PASC-SEIU Plan network. Effective January 1, 2014, L.A. Care updated its internal systems and processes to identify the product as the PASC-SEIU Plan, instead of the IHSS Plan, to avoid confusion with the IHSS benefit under Medi-Cal/Long-Term Services and Supports. L.A. Care Cal MediConnect Medicare-Medicaid Plan (MMP) The Coordinated Care Initiative (CCI) in California, passed into law in 2012, was created to respond to the needs of dual eligible beneficiaries and to deliver higher quality and more integrated care. Overall, the CCI strives to improve the integrated delivery of medical, behavioral, and long-term care services for beneficiaries. Cal MediConnect (CMC) is one of the key components of the CCI and was launched in Los Angeles County in April CMC is a voluntary demonstration for dual eligible beneficiaries to receive coordinated medical, behavioral health, long-term institutional, and home-and community-based services through a single organized delivery system. The Cal MediConnect program aims to improve care coordination for dual eligible beneficiaries through the provision of high quality care that helps people stay healthy and in their homes for as long as possible. Additionally, shifting services out of institutional settings and into the home and community will help create a person-centered health care system that is also sustainable. Currently, the demonstration is authorized through December 31, CMS has announced its intention to extend the MMP demonstration for an additional two years through the end of The Governor of California and the California Department of Health Care Services have also agreed to extend the demonstration as reflected in the Governor s Budget Assembly Bill 113. L.A. Care s Cal MediConnect program aims to provide a seamless service delivery experience with the ultimate goals of improving care quality, better health and a more efficient delivery system. L.A. Care currently serves about 16,000 members in Cal MediConnect. A specific focus of CMC is delivering patient centered care through a Care Management approach that creates an interdisciplinary team working collaboratively to Q I P r o g r a m D e s c r i p t i o n

9 meet the needs of the CMC member from a medical, psychological, social needs and community support perspective. Managed Long Term Services and Supports (MLTSS) L.A. Care s Managed Long Term Services and Supports (MLTSS) Department provides services that help individuals remain living independently in the community and oversees extended long-term care provided in a skilled nursing or intermediate care facility. MLTSS serves L.A. Care s members enrolled in the California Coordinated Care Initiative (CCI)/Cal MediConnect (CMC) and Medi-Cal. In 2014 the California Department of Health Care Services (DHCS) began the transition of the MLTSS benefit to L.A. Care. MLTSS oversees five programs: Long Term Care (LTC) Nursing Facilities; Community Based Adult Services (CBAS); Multipurpose Senior Services Program (MSSP); In-Home Supportive Services (IHSS); and Care Plan Options. MLTSS also supports member and staff inquiries and makes referrals to L.A. Care and community resources. Conceptual Framework The conceptual framework for the QI Program aligns with the National Quality Strategy. The National Quality Strategy presents three aims originally by the Institute for Healthcare Improvement (IHI) for the health care system, known as the Triple Aim. As a partner with CMS and the state of California on numerous programs, L.A. Care must align its quality program and initiatives with the Triple Aim. The Triple Aim is defined as: Population Health: Improve the overall quality of care, by making health care more patient-centered, reliable, accessible, and safe. Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care. Patient Experience: Improve overall satisfaction with care and services through safe, effective and accessible patient-centered delivery. Per Capita Cost: Reduce the cost of quality health care for individuals, families, employers, and government. [1] Furthermore, in order to achieve these aims, the strategy established five priorities, to help focus efforts by public and private partners including L.A. Care Health Plan. Those priorities are: 1) Improve medical care by increasing quality and the responsiveness of care networks. 2) Improve member and provider satisfaction with L.A. Care. 3) Implement an operational excellence strategy to excel at the full range of product lines offered by L.A. Care. 4) Improve financial sustainability of direct product lines. [1] ( Q I P r o g r a m D e s c r i p t i o n

10 5) Ensure access to care for low income and vulnerable populations through supporting the safety net and demonstrating value of the Local Initiative under the Medi-Cal Two-Plan model. As the QI program aligns with the Triple Aim, there is increased integration of Medical Management and Quality Improvement in the QI program structure. GOALS AND OBJECTIVES The L.A. Care Quality Improvement Program, consistent with the L.A. Care mission, strives to improve clinical care, safety and service through the following goals and objectives: Goal Improve Quality of Care: Improve and maintain the health and wellness of its members through the provision of coordinated, comprehensive, quality care for each member including those with complex health needs, such as, the Seniors and Persons with Disabilities (SPD) population. Objectives: Improve access to high quality care for all covered lives Improve NCQA accreditation rating HEDIS scores per work plan targets. Improve Medicare Star ratings. (although not publically reported L.A. Care will track performance) Improve provider encounter data reporting. Improve our provider network data and adequacy. Utilizing a multi-disciplinary approach to assess, monitor and improve our policies and procedures. Promoting physician involvement in our Quality Improvement Program and activities. Meeting the changing standards of practice of the healthcare industry and adhere to all state and federal laws and regulations. Ensuring there is a separation between medical and financial decision making. Seeking out and identifying opportunities to improve the quality of care and services provided to our members and practitioners. Confirm that the quality improvement structure and processes maintained by L.A. Care comply with provisions of the L.A. Care Quality Improvement Program and meet state, federal, NCQA and other applicable professionally recognized standards. Coordinate relevant sources of information available to L.A. Care including quality of care performance review (e.g. QI activities reports, utilization management, member services, pharmacy, and other data). Collect and analyze data related to the goals and objectives and establish performance goals to monitor improvement including Managed Long-Term Services and Supports (MLTSS) [Community Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP), and In-Home Support Services Q I P r o g r a m D e s c r i p t i o n

11 (IHSS) and Long-Term Care (LTC)/Skilled Nursing Facility (SNF) and other facilities through an organized committee structure. Identify opportunities for process improvement within L.A. Care, its delegates and contracted entities to drive patient-centric quality care and service by utilizing performance data to drive the QI process. Implement, monitor, and evaluate interventions to ensure members receive the highest quality healthcare available. Communicate the quality improvement process to practitioners/providers and members through appropriate persons and venues (e.g. meetings, print media, electronic media, and L.A. Care s website). Evaluate the Quality Improvement Program annually and modify the program as necessary to improve program effectiveness. Develop, monitor and operationalize a QI work plan that addresses quality and safety of clinical care and service, program scope, yearly objectives, planned activities, timeframe for each activity, responsible staff, monitoring previously identified issues, and conducting an annual evaluation of the program. Goal Monitor and Improve Patient Safety: Promote, monitor, evaluate and improve quality healthcare services through a system of collaboration between L.A. Care and its providers and practitioners by promoting processes that ensure timely, safe, effective, medically necessary, and appropriate care is available. In addition, L.A. Care monitors whether the provision and utilization of services meets professionally recognized standards of practice. Objectives: Identify, monitor, and address known or potential quality of care issues (PQIs) and trends that affect the health care and safety of members and implement corrective action plans as needed. Ensure that mechanisms are in place to support and facilitate continuity of care and transition of care within the health care network and to review the effectiveness of such mechanisms. Establish, maintain, and enforce a policy regarding peer review activities including conflict of interest policy. Through credentialing, recredentialing and ongoing monitoring, promptly identify and address any issues with network providers that may impact patient safety for our covered population. Establish standards of medical and behavioral health care (as required by product line) which reflect current medical literature and national benchmarks; design and implement strategies to improve compliance; and develop objective criteria and processes to evaluate and continually monitor performance and adherence to the clinical and preventive health guidelines. Foster a supportive environment to assist practitioners and providers to improve safety within their practices (e.g., member education information specific to clinical safety related to overuse of antibiotics or provider notifications of polypharmacy, etc.) Monitor tracking and reporting of critical incidents impacting patient safety from downstream entities and vendors Q I P r o g r a m D e s c r i p t i o n

12 Identify and monitor patient safety measures for in-network hospitals and collaborate with other payers and stakeholders to help them achieve minimal performance targets. Track Low-Risk NTSV C-Section rates for in-network maternity hospitals and collaborate with other payers and stakeholders such as the CMQCC and CHCF to help them meet or exceed the national goal of 23.9% Goal Improve Member Satisfaction: Improve member satisfaction with the care and services provided by L.A. Care s network of providers and identify potential areas for improvement through review of multiple sources of data including evaluation of member complaints, grievances, and appeals as well as data collected from the annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Streamline and coordinate all communications with members. Objectives: Improve overall rating of the health plan on the CAHPS Survey. Identify key drivers that affect CAHPS scores of the health plan. Collaborate with the Customer Solution Center to implement company-wide initiatives to improve our ability to provide exemplary service to our members and providers. Share C-G CAHPS data with provider groups, instruct them how to interpret the results and promote member experience interventions and best practices among PPGs, MSOs and physician practices/clinics. Prioritize areas that impact rating of the health plan. Periodic review of key service-related reports from both the health plan and delegated entities (e.g., Customer Solutions Center, PBM, Behavioral Health and Nurse Advice Line service reports) to identify opportunities to improve service and customer satisfaction. Leverage Appeals and Grievances data to gain insight into the drivers of member dissatisfaction and develop interventions to address these concerns in collaboration with vendors and delegated entities. Identify key areas for improvement, develop and monitor interventions based on the findings in the key service-related reports. Monitor results of the interventions. Consolidate multiple data sources in developing the analysis. Ensure that the provision of healthcare services is accessible and available in order to meet the needs of our members. Incorporate electronic media and venues to enhance member and provider engagement and address NCQA Member Connections Standards. Goal Provide Culturally and Linguistically Appropriate Services: Ensure medically necessary covered services are available and accessible to members regardless of race, color, national origin, creed, ancestry, religion, language, age, gender, marital status, sexual orientation, gender identity, health status, physical or mental disability, or identification with any other persons or groups defined in Penal Code , and that all Covered Services are provided in a culturally and linguistically appropriate Q I P r o g r a m D e s c r i p t i o n

13 manner by qualified, competent practitioners and providers committed to L.A. Care s mission. Promote health education and disease management that is age-defined, culturally and linguistically appropriate, condition-specific, and designed to promote life-long wellness by encouraging and empowering the member to adopt and maintain optimal health behaviors. Objectives: Analyze existence of significant health care disparities in clinical areas. Assess the cultural, ethnic and linguistic needs of member. Identify and reduce specific health care disparities. Promote preventive health measures, health awareness programs, education programs, patient safety, health care disparities, and cultural and linguistic programs that complement quality improvement interventions. Provide culturally appropriate health education services in order to enhance members health status. Ensure the availability and accessibility of cultural and linguistic services such as 24/7 interpreting services including American Sign Language (ASL) as well as materials translated and in alternative formats. Conduct member focused interventions with culturally competent outreach materials that focus on race/ethnicity/language specific risk. Maintain Multicultural Healthcare Distinction Certification. Goal Improve the Delivery of Care for Persons with Complex Health Care Needs: Ensure the delivery and coordination of care of members with complex health needs through case management, complex case management, and effective liaisonship with services that are linked or carved out, such as, the Regional Centers (Disabilities) and the Department of Mental Health (DMH) and Department of Public Health (DPH). Objectives: Provide case management to those with complex health care needs, such as Seniors and Persons with Disabilities. Improve access to primary and specialty care ensuring that members with complex health conditions receive appropriate service through audits, medical record reviews, and other oversight activities. Use care coordinators and case managers for members who receive multiple services. Identify and reduce barriers to services for members with complex conditions. Sponsor the delivery of educational information to practitioners to enhance the diagnosis and treatment of medical/health conditions, those with Complex Health Care Needs. Address and resolve patient-specific issues including those with complex health needs, such as, SPDs Q I P r o g r a m D e s c r i p t i o n

14 Goal Provide a Network of High Quality Providers and Practitioners: Maintain a well-credentialed network of providers and practitioners based on recognized and mandated credentialing standards and cultural/linguistic needs of members. Provide continuous quality improvement oversight to the provision of health care within the L.A. Care system network by monitoring and documenting the performance of L.A. Care s contracted network through facility site reviews, medical record reviews, HEDIS scores, and other focused studies. Objectives: Establish and maintain policies, procedures, criteria, and standards for the credentialing and recredentialing and ongoing monitoring of plan practitioners and organizational providers. Educate practitioners regarding L.A. Care s performance expectations and provide feedback about compliance with those expectations. Monitor and document the performance of network practitioners in providing access and availability to quality care through the use of health-related indicators, member satisfaction surveys, provider satisfaction surveys, access and availability surveys, focused studies, facility inspections, medical record audits, and analysis of administrative data (e.g., grievance and appeals data). Incorporate NCQA Network Management Standards into policies and procedures and workflows regarding Access and Availability of providers and services. Collaborate with other key external stakeholders to assess hospital quality and performance measures and establish expectations for continued network participation. Systematically collecting, screening, identifying, evaluating and measuring information about the quality and appropriateness of clinical care and provide feedback to IPA/PMG s and Practitioners about their performance and also the network-wide performance. Objectively and regularly evaluating professional practices and performance on a proactive, concurrent and retrospective basis through Credentialing and peer review. Goal Monitor and Improve Behavioral Healthcare: Monitor and improve behavioral healthcare and coordination between medical and behavioral health care. Objectives: Collaborate with behavioral health practitioners and entities to ensure appropriate utilization of behavioral health services and continuity and coordination of medical and behavioral healthcare. Improve communication (exchange of information) between primary care practitioners and behavioral health practitioners. Monitor the appropriate diagnosis, treatment and referral of behavioral health care disorders commonly seen in primary care. Monitor appropriate use and monitoring of psychopharmacological medications. Manage treatment access and follow-up for members with coexisting medical and behavioral disorders Q I P r o g r a m D e s c r i p t i o n

15 Screening for depression members with chronic diseases, promote routine screening for depression in the adolescent and adult population, including those with chronic disease and women during pregnancy and the postpartum period and ensuring appropriate follow-up. Identification and management of Substance Use Disorders. Goal Meet Regulatory and Other Health Plan Requirements: Consistently meet quality standards as required by contract, regulatory agencies, recognized care guidelines, industry and community standards, and this Quality Improvement Program. Objectives: Monitor L.A. Care and network compliance with the contractual and regulatory requirements of appropriate state and federal agencies and other professional recognized standards, such as, NCQA and Joint Commission. Maintain grievance and appeal procedures and mechanisms and assure that members can achieve resolution to problems or perceived problems relating to access or other quality issues. Establish, maintain, and enforce confidentiality policies and procedures for protection of confidential member, practitioner, and provider information in accordance with applicable state and federal regulations. Protect member identifiable health information by ensuring members protected health information (PHI) is only released in accordance with federal, state, and all other regulatory agencies. L.A. Care does not exert economic pressure to cause institutions to grant privileges to providers that would not otherwise be granted, nor to pressure providers or institutions to render care beyond the scope of their training or experience. Assuring compliance with the requirements of accrediting and regulatory agencies, including but not limited to, DHCS, DMHC, CMS, NCQA and Covered California. Goal Monitor Quality of Care in Long Term Care Nursing Facilities and Community-Based Adult Services (CBAS) Facilities L.A. Care monitors its contracted Long Term Care (LTC) Nursing Facilities and Community-Based Adult Services (CBAS) Facilities to ensure quality and coordination of long term care services for members. Objectives: Review state regulatory oversight of LTC and CBAS facilities and develop and maintain a process to identify and address quality issues through the credentialing, recredentialing and ongoing monitoring process. Review existing LTC Nursing Facility quality indicators and standards and establish how these can be leveraged in the credentialing, recredentialing and ongoing monitoring process. Maximize member referrals for appropriate MLTSS services from provider groups and internal care management processes. In addition to new referrals, this includes expansion of existing MLTSS services to help maintain functional status and social skills such as non Q I P r o g r a m D e s c r i p t i o n

16 severely impaired members receiving IHSS who may benefit from CBAS or more impaired IHHS members who may benefit from MSSP. Through LTC placement referrals and review of higher functioning existing LTC members, identify those who can remain or return to a community-based residence with appropriate support services. Goal Provide an Evidence Based Model of Care: L.A. Care must implement an evidence-based Model of Care and evaluate the effectiveness of the care management process, which includes the quality improvement activities designed for these individuals that have measureable outcomes Objectives: Improve access to essential services such as medical, mental health and social services Improve access to affordable care Assuring appropriate utilization of services Improve coordination of care through an identified point of contact Improve seamless transition of care across healthcare setting, providers, and health services Improve access to preventive health services Improve beneficiary health outcomes. AUTHORITY AND ACCOUNTABILITY The Board of Governors (BoG) has ultimate accountability for L.A. Care s Quality Improvement Program. The Board of Governors approves the QI Program Description. L.A. Care Health Plan s Governing Body is the thirteen (13) member stakeholder Board of Governors (BoG). As a public entity, all meetings of the BoG and its subcommittees are conducted within the rules and regulations of the Brown Act (California Open Meeting Law). Officers are elected annually. The members represent the following Los Angeles County stakeholder groups including but not limited to Free and Community Clinics, Private Disproportionate Share Hospitals (DSH), Federally Qualified Health Centers (FQHC), Knox Keene Licensed Pre-Paid Health Plans (California Association of Health Plans), Los Angeles County (Department of Health Services, Board of Supervisors), Children s Health Care Providers, Private Non-Disproportionate Share Hospitals, L.A. Care Member Advocates, L.A. Care Members and Physicians (L.A. County Medical Association). The Board has assigned oversight of the QI Program to the Compliance and Quality Committee (C&QC), a subcommittee of the Board. The Compliance and Quality Committee (C&QC) has final approval of the QI Program Description and the Quality Improvement Annual Evaluation annually. The C&QC monitors all quality activities and reports its findings to the Board of Governors. The Chief Medical Officer and the Medical Director, Quality Improvement & Health Assessment provide regular reports to the C&QC from the Quality Oversight Committee. Discussions, Q I P r o g r a m D e s c r i p t i o n

17 conclusions, recommendations, and approval of these reports are maintained in the minutes of the C&QC and BoG meetings. Meeting Schedule The BoG has scheduled ten (10) meetings per year. All draft meeting agendas are publicly posted 72 hours prior to the meeting. The final agenda is approved at the time of the meeting in accordance with the Brown Act. ORGANIZATIONAL STRUCTURE Following an organizational restructure in , L.A. Care continues to operate under a matrix-management model, which designates leaders by product line/population segments and also, Chief Executives over specific business units. This leadership team works together to align business processes to foster accountability internally and externally; eliminate duplication of functions; clarify communication with internal and external stakeholders; and add new functions in internal auditing, enterprise risk assessment, and single source for data management and analytics. The following figures were used to display accountability by product line/population segment and the matrix organization proposed and the organization under CEO. The realignment of functions and accountability is reflected in the narrative description and roles and responsibilities outlined in this document. Chief Operating Officer The Chief Operating Officer (COO) is a senior member of the executive management team and reports directly to the Chief Executive Officer (CEO). The COO is responsible for the overall operational and administrative performance of enterprise functions. This position has organizational-wide responsibility to ensure a well-run and administratively capable organization. Reporting to the position are the departments and functions that are focused on core health plan operations, such as membership services, human resources, information technology, claims, and provider network. The COO works closely with Product Line Executives and provides services and advice to ensure proper functioning of the product lines and achievement of strategic goals. Chief Financial Officer The Chief Financial Officer (CFO) is a senior member of the executive management team and reports directly to the Chief Executive Officer (CEO). The CFO is responsible for all areas of accounting, finance, treasury, budgeting, revenue management & provider reimbursement, financial risk management, financial compliance/audit, materials procurement and fixed asset management. Provide financial leadership and advice, both strategic and tactical financial perspectives, to the Board of Governors & L.A. Care senior management as it relates to financial performance and the interpretation of key financial information to enhance the overall effectiveness of the management decision making process. Develop, enhance, and enforce policies and procedures that will improve the overall operation and effectiveness of L.A. Care's internal controls. The CFO will work closely with Product Line Executives and provide services and advice to ensure proper functioning of the product lines and achievement of strategic goals Q I P r o g r a m D e s c r i p t i o n

18 Chief of Enterprise Integration The Chief of Enterprise Integration is responsible for managing the data analytics, process improvement, risk management, and the Project Management Office department. The Chief of Enterprise Integration reports directly to the Chief Executive Officer and will coordinate implementation of a matrix management model that integrates operations to support discrete lines of business in an optimally efficient and effective manner. The Chief of Enterprise Integration manages all data analytic activities that will improve access to and accuracy of data, utilize a single source of data (e.g., enterprise data warehouse), define options for improving workflow management and data integration that optimize core functions and enable planned growth, and improve the organization s overall ability to make data-driven decisions. In addition, the Chief of Enterprise Integration collaborates with business stakeholders and I.T. to ensure that all necessary data is stored in the Enterprise Data Warehouse in a timely manner to ensure that reports and analysis are available in a timely manner. The Chief of Enterprise Integration is responsible for management of the overall process improvement program, which supports L.A. Care's strategic goals and coordinates and evaluates continuous business process improvement initiatives. Manages and coordinates organization-wide efforts to ensure that performance management and quality programs are developed and managed using a data-driven focus that sets priorities for improvements aligned to ongoing strategic imperatives. Develops standardized procedures for identifying, assessing, and addressing operational needs that enhance core functions and facilitate growth objectives. Designs a process to standardize provider recruiting, contracting, and communications. Builds a performance management team of process engineers and project managers to document operational issues and gaps, develop remediation/risk mitigation proposals for review and approval by leadership. The Chief of Enterprise Integration is responsible for risk management activities, including but not limited to identification, benchmarking/metrics, and mitigation. Provides assistance by planning, coordinating and directing programs, studies and special projects in support of risk management activities. Utilizes innovation, knowledge and expertise to recommend mitigation plans. Directs and coordinates staff and activities to ensure that risk management practices, governance standards, processes, and metrics. The Chief of Enterprise Integration is responsible for the management of the Project Management Office (PMO) functions at L.A. Care. This includes, but is not limited to, all PMO methodology, processes and procedures, and large scale corporate projects. Through cross-functional teams, this position is responsible for the success of the PMO function through planning, developing and implementing a comprehensive plan to meet desired outcomes. Defines and implements asset optimization and return of investment models, infrastructure support, and proactive enterprise wide project portfolio reviews on an ongoing basis. Reviews enterprise wide projects and assists in identifying and establishing priorities, metrics, and processes. Manages the development and maintenance of a project scorecard, promotes project management within the organization, and participates in strategic planning. Oversees staff responsible for performance management activities (i.e., Project Managers and Project Analysts), process improvement evaluation and redesign, risk management, and data analytics Q I P r o g r a m D e s c r i p t i o n

19 Chief Quality and Information Executive The Chief Quality and Information Executive (CQIE) works collaboratively with the CMO and is a key position on the Health Services team. Under the Quality Improvement umbrella are four areas: HEDIS, Disease Management, Quality Improvement, and Accreditation & Oversight. Responsibility to improve quality for vulnerable populations. Needs to implement strategy for the quality improvement function within the health plan, in collaboration with the administrative and clinical leaders of the organization. Must track and present results of improvement efforts and ongoing measures of clinical processes. Oversee regulatory readiness, quality measurement, and pay for performance programs and initiatives. Establish improvement activities, including methods to track implementation of action plans following site surveys and critical events reviews. The individual must maintain current competency in quality regulations and standards. The role will lead and be responsible for the planning and implementation of clinical information systems (CIS) used in the organization. Will assist in developing the vision and plan for the adoption of the new digital solutions and analysis for clinical process improvement. Reports directly to L.A. Care's Chief Medical Officer (CMO). May lead Data Governance Committees, Clinical Advisory Groups, and serve as liaison to various departments in bridging best practices with CIS solutions. General Counsel The General Counsel provides or arranges for the provision of legal services for the organization. Executive Director Medi-Cal Plan Partners The Executive Director of Medi-Cal Plan Partners will take specific responsibility for delivering top line revenues, net operating results and outstanding compliance and quality score results for a population segment product of the L.A. Care portfolio. The Executive Director is responsible for strategically evaluating, planning and leading complex business initiatives that support the strategic goals of a population segment product. The Executive Director is responsible for the quality, compliance and operational performance of L.A. Care s Medi-Cal subcontracted health plans: Anthem Blue Cross, Care 1 st, and Kaiser. In addition, L.A. Care operates a Medi-Cal direct line of business, L.A. Care Medi-Cal. The program serves multiple member demographics and cultures throughout Los Angeles County. Executive Director Medi-Cal, TANF, and MCE The Executive Director of Medi-Cal TANF, MCE will take specific responsibility for delivering top line revenues, net operating results and outstanding compliance and quality score results for a population segment product of the L.A. Care portfolio. The Executive Director is responsible for strategically evaluating, planning and leading complex business initiatives that support the strategic goals of a population segment product Q I P r o g r a m D e s c r i p t i o n

20 The Executive Director is responsible for the quality, compliance and operational performance of L.A. Care s Medi-Cal direct line of business and L.A. Care Medi-Cal. Members are provided health care and coordinated services through L.A. Care s contracted network of providers, hospitals, pharmacies and ancillary service providers throughout Los Angeles County. Membership includes children, families and now serves adults. Executive Director Medi-Cal SPD, CCI The Executive Director of Medi-Cal SPD/CCI will take specific responsibility for delivering top line revenues, net operating results and outstanding compliance and quality score results for a population product segment of the L.A. Care portfolio. The Executive Director is responsible for strategically evaluating, planning and leading complex business initiatives that support the strategic goals of a population product segment. The Executive Director is responsible for the quality, compliance and operational performance of L.A. Care s Medi-Cal SPD/CCI population segments that are assigned to a directly contracted network and consists of Seniors and Persons with Disabilities and beneficiaries enrolled in the Coordinated Care Initiative. Executive Director Cal MediConnect (CMC) The Executive Director of Cal MediConnect will take specific responsibility for delivering top line revenues, net operating results and outstanding compliance and quality score results for a population segment product of the L.A. Care portfolio. The Executive Director is responsible for strategically evaluating, planning and leading complex business initiatives that support the strategic goals of a population segment product. The Executive Director will oversee L.A. Care s product for Seniors and Persons with Disabilities who are eligible for both Medicare and Medi-Cal and enrolled in the duals demonstration pilot. Executive Director L.A. Care Covered (LACC) & PASC-SEIU The Executive Director for L.A. Care Covered & PASC-SEIU will take specific responsibility for delivering top line revenues, net operating results and outstanding compliance and quality score results for a population segment product of the L.A. Care portfolio. The Executive Director is responsible for strategically evaluating, planning and leading complex business initiatives that support the strategic goals of a population segment product. The Executive Director will oversee the following products: 1) L.A. Care Covered: A Covered California health benefits exchange product. Membership is approximately 15K. 2) PASC-SEIU Homecare Workers Health Care Plan: Health coverage to Los Angeles County s In-Home Supportive Services (IHSS) workers, who provide in-home services such as meal preparation and personal care services to Medi-Cal beneficiaries. Membership is approximately 45K Q I P r o g r a m D e s c r i p t i o n